Deadly delays plague several VA medical centers

The American Legion Online Update e-newsletter

At least 19 veterans have died recently at Department of Veterans Affairs (VA) facilities because of delays in simple medical screenings, according to an internal VA document obtained by CNN.

These screenings, such as colonoscopies or endoscopies, can often mean the difference between life and death. About 7,000 veterans were on a backlog list to receive such screenings at VA facilities in Columbia, S.C., and Augusta, Ga.

Last September, VA’s Office of Inspector General (OIG) reported that six patient deaths at the William Jennings Bryan Dorn VA Medical Center in Columbia were linked to delayed screenings for colorectal cancer. OIG also concluded that delayed colonoscopies and other screenings were linked to malignancies found in another 52 patients.

The American Legion contacted the OIG last December to obtain more information on their findings in advance of a System Worth Saving (SWS) site visit to the Columbia facility on March 4. During that discussion, the OIG explained why the screenings became backlogged. When a patient’s primary care provider sends a gastroenterology (GI) consult, it is sent electronically to the medical center’s GI administration. But no one was looking at the consults coming in, which led to the backlog.

The report noted that another factor in creating the backlog was the Columbia facility’s high turnover in personnel.

In April, the Legion’s SWS team will seek to determine what plan of action the Columbia VA medical center has implemented to prevent future delays in screenings for patients. Another SWS team was scheduled to visit the VA medical center in Augusta, Ga., on Jan. 30-31, but the visit was cancelled because of a snowstorm in the deep south.

According to CNN, veterans have died from delayed screenings at several other VA facilities in Florida, Texas and the Rocky Mountain region. The American Legion’s SWS teams have already made site visits to VA hospitals in Atlanta and El Paso, Texas. Besides the Columbia trip in March, SWS team will also evaluate the quality of VA health care at facilities in Denver, Dallas and Orlando, Fla.

The American Legion’s SWS teams compile reports from interviews with patients, administrators and medical staff, and share them with Congress, the White House and senior VA leadership. They are also available online here.

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w w clark

va clinic in casa grande, az have been patient for 4 years. medical staff very good, however, my phone calls have been hung up on, put on hold for a very long time, no answer many times, snotty service when they deigned to talk to me. the result is that I have had to travel 200 miles round trip to VA Tucson to get things taken care of whereas if I could have connected to someone, other than the MSA at casa grand, travel time could have been shortened. I am vet of 75yo with multiple chronic diseases.

Savanna

WAC

I've used the VA in Oklahoma City off and on for 30 years. Until recently, I never had the same primary more than a year, and usually had a male (no offense, but they don't know sic 'em from come here about caring for female vets) I now use secure messaging to communicate with my primary, which is great due to the distance involved, and being unable to drive myself. In the past, I had similar communication problems (staff not returning calls, not passing messages to doctor, calling wrong number, etc.) Referrals to specialty clinics frequently don't get made, get delayed, then have to wait 6 weeks to as long as 6 months to be seen. They are unable or unwilling to consolidate appointments (necessary due to distance and having to arrange for transportation) There are literally a dozen or more instances of problems being ignored until I had to go to a private doctor or specialist to get a diagnosis, then taking the evidence back to the VA and say, see, there really is something wrong. Most of this was very expensive and frequently out of my own pocket. The inpatient care has improved, as I recently received excellent care in the Surgical ICU. Unfortunately, as soon as I was discharged, the care returned to the old "left hand not knowing what the right hand was doing" A month later, and they're still fussing back and forth about the meds (it wasn't planned ahead of time, I had to call repeatedly to get it started.)
I firmly believe there have been improvements made in the last few years--my current primary is very good and honestly seems to care what happens to me. However, she is trying to practice good medicine in a cumbersome, ineffective system that is basically designed to run patients through like cattle, and save as much money as they can.

Edward G.

I use the clinic in Mobile, Al. I have been a cardiac patient for over twenty years including 8 heart attacks, 3 stents, and five by-passes in a single surgery. My primary care doctor has not placed a stethoscope to my chest in at least five years. They act like you work for them all over this facility instead of the other way around. For many years I used the VAMC in Topeka, Ks. and it was an outstanding facility in every way. I moved here ten years ago and wish I had stayed in Kansas. The old saying the grass is always greener is really a fact in my case.

Edward Heldman, Sun City, AZ

I had an aortic valve replacement done in the TUCSON, AZ VA Hospital in July 2013. The surgery was successful but the post-surgery care was deplorable. I had minimal follow up doctor visit to keep me informed of how I was doing, and the nurses (with some exceptions) were pathetic and couldn't have cared less about my medical complaints. A couple of nurses were downright abusive. One day after surgery, I was physically restrained to my bed because the effects of the meds being given to me by that hospital staff made me unable to comprehend the nurse commands to 'walk and how to breath.' I suffered with being unable to walk any reasonable distance for two weeks while in their care until I finally discharged myself AMA. Within one week after leaving the Tucson VA Hospital, I was admitted to the ER at PHX VA Hospital and my breathing and walking medical problems were finally properly diagnosed and treated. I found the Tucson, AZ VA Hospital Cardiac Surgery 'staff' to be arrogant and full themselves probably due to its high reputation for its surgical procedures, but certainly not for its patient post-operative care! I attempted to file a complaint through Tucson VA’s ‘Patient Advocate’ office but received no response to my communications seeking instructions for doing so.

Savanna

My. Husband had an mitral valve replaced April, 2012 what a nightmare, the swan ganz used was not purged by the ICU nurse, he developed a fib and it was leaking onto his chest, he had a 11 hour surgery, after 6 days moved downstairs for another 5 days, released with raging staph in his chest, called Tucson no one available rushed to phx va where they jetted him back to Tucson for an emergency surgery ( endocartitus) from the infection, he had an open chest for 6 weeks and 6 more surgeries, has no connected sternum, absolutely horrifying, they are uncaring and just smile pat your shoulder and say sorry
Stay away from that crazy uncaring incompetent place

Larry Cummings

VA service has declined at the Long Beach, CA facility the last couple of years. You can't reach your primary care Doctor without going the chain of command, starting with the maintenance people, it's like they don't care any more, don't return calls, don't follow up on procedures, etc. Thanks Mr. president.

A

Yes, I agree. Have been in therapy with a psychologist for 20 years due to some deep seated issues and all of a sudden I have to go to some intake meeting then if I want individual therapy, I have to go to another meeting and after that I have to make 3 "POM" meetings and if I miss one I have to start all over as they have to be consecutive. So I completed the first two intake meetings and then was involved in a domestic violence dispute and desperately needed individual counseling. But here I sat listening for the third time about privacy, hipa, report of elder and child abuse, parameters of therapy and that we will only be offered short term therapy. It was all I could do to listen to this. I interrupted the presenter to let her know of my situation and received one individual therapy session on an emergency basis. In the mean time, I missed my second POM session due to a death and now have to reschedule. AT THIS POINT, I REALLY NEED TALK THERAPY!!! I agree, the VA system is no longer providing good service. Seems they have more rule about things which prevent actual work from getting accomplished.

Richard E Samples,Sr

The last colonoscopy I had in the Atlanta,Ga. VA. I was 55yrs. old I am now 69 the VA does not do colonoscopies any more unless you have a problem to show ( UP First. ) I thank that is a little to late. Also the VA records show that I did not have the colonoscopy their when I was 55. So I guess I did it my self in a back room? WE VETS HAVE SHOUCH A GREAT VA IN ATLANTA, GA ( I have had medical malpractice, over doses & very very bad or no dental services!!! And I am a 100% disable vet. I guess 1000% mite get better service. Richard